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Desai P, Navkudkar A, Bagal B, Dhamne C, Jain H, Sengar M, Chinnaswamy G, Nayak L. Navigating the neutropenic abyss with granulocyte transfusions: Retrospective single-center analysis of effectiveness and safety in India. J Clin Apher 2023; 38:703-710. [PMID: 37560907 DOI: 10.1002/jca.22084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/22/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Hemato-oncologic patients receiving intensive chemotherapy may develop severe neutropenia and serious bacterial and/or fungal infections. Granulocyte transfusions (GTs) may be beneficial as a bridging therapy in hemato-oncologic patients with febrile neutropenia. AIM To evaluate the clinical effectiveness of GTs in hemato-oncologic patients with febrile neutropenia. MATERIALS AND METHODS This retrospective study evaluated the effectiveness of 150 GTs in 88 hemato-oncologic patients. Donors were mobilized with granulocyte colony-stimulating factors and dexamethasone. Patients' hematological parameters (pre- and post-GT) and safety and effectiveness of GTs were analyzed. RESULTS The safety and effectiveness of GTs were assessed in the patients with various underlying conditions, including 78% with acute myeloid leukemia. In total, 150 GTs were administered, mostly during the chemotherapy induction phase. The GTs were well-tolerated by the patients, and a significant increment in white blood cell count and absolute neutrophil count (ANC) was noticed in 95% of patients after the transfusion. The granulocyte dose was positively correlated with ANC after the transfusion. The average time to neutrophil recovery from the last day of GT was 6.7 days, and the 30-day survival rate was 77%. The donors were all men, and a significant increase in WBC count was observed post-mobilization. The median granulocyte yield was 2.28 × 1010 /unit. All granulocyte products were crossmatched and irradiated before the transfusion. CONCLUSION GTs can be a useful adjunctive treatment for febrile neutropenia in hemato-oncologic patients with multidrug-resistant sepsis. However, additional studies are required for confirming their effectiveness and establishing guidelines for their use.
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Affiliation(s)
- Priti Desai
- Department of Transfusion Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anisha Navkudkar
- Department of Transfusion Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Bhausaheb Bagal
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Chetan Dhamne
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Hasmukh Jain
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Lingaraj Nayak
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Yin T, Han J, Hao J, Yu H, Qiu Y, Xu J, Peng Y, Wu X, Jin R, Zhou F. Clinical characteristics and risk factors of acute lymphoblastic leukemia in children with severe infection during maintenance treatment. Cancer Med 2023; 12:19372-19382. [PMID: 37768027 PMCID: PMC10587982 DOI: 10.1002/cam4.6495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Infection is the most common adverse event of acute lymphoblastic leukemia (ALL) treatment and is also one of the main causes of death. METHODS To investigate the clinical characteristics and risk factors of severe infections during the maintenance phase of ALL treatment, we conducted a retrospective study. RESULTS A total of 181 children were eligible and 46 patients (25.4%) suffered from 51 events of severe infection, most of which occurred in the first half year of the maintenance phase (52.9%). The most common infection was pulmonary infection (86.3%) followed by bloodstream infection (19.6%). The main symptoms of ALL patients with pulmonary infection were fever, cough, and shortness of breath. The main manifestations of computer tomography (CT) were ground glass shadow (56.8%), consolidation shadow (27.3%), and streak shadow (25%). Multivariate binary logistic regression analysis showed that agranulocytosis, agranulocytosis ≥7 days, anemia, and low globulin level were independent risk factors for severe infection during the maintenance phase (all p < 0.05). CONCLUSIONS Taken together, blood routine examinations and protein levels should be monitored regularly for ALL patients in the maintenance phase, especially in the first 6 months. For ALL patients with risk factors, preventive anti-infective or supportive therapies can be given as appropriate to reduce the occurrence of severe infections.
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Affiliation(s)
- Tiantian Yin
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Juan Han
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jinjin Hao
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Hui Yu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yining Qiu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jiawei Xu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yun Peng
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Runming Jin
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Fen Zhou
- Department of Pediatrics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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3
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Morton S, Fleming K, Stanworth SJ. How are granulocytes for transfusion best used? The past, the present and the future. Br J Haematol 2023; 200:420-428. [PMID: 36114720 DOI: 10.1111/bjh.18445] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 02/04/2023]
Abstract
Granulocyte transfusions continue to be used in clinical practice, predominantly for treatment of refractory infection in the setting of severe neutropenia. There is biological plausibility for effectiveness in these patients with deficiencies of neutrophils, either as a consequence of disease or treatment. However, there is a chequered history of conducting and completing interventional trials to define optimal use, and many uncertainties remain regarding schedule and dose. Practice and clinical studies are severely limited by the short shelf life and viability of current products, which often restricts the timely access to granulocyte transfusions. In the future, methods are needed to optimise donor-derived granulocyte products. Options include use of manufactured neutrophils, expanded and engineered from stem cells. Further possibilities include manipulation of neutrophils to enhance their function and/or longevity. Granulocyte transfusions contain a heterogeneous mix of cells, and there is additional interest in how these transfusions may have immunomodulatory effects, including for potential uses as adjuncts for anti-cancer effects.
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Affiliation(s)
- Suzy Morton
- Transfusion Medicine, NHS Blood and Transplant, Birmingham, UK.,University Hospitals Birmingham, Birmingham, UK
| | - Katy Fleming
- Bristol Haematology and Oncology Centre, Bristol, UK.,School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
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4
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Koo S, Offner R, Haile SM, Brosig A, Hähnel V, Gruber M, Burkhardt R, Ahrens N. Granulocyte concentrate splitting does not affect phenotype and function. Transfusion 2023; 63:393-401. [PMID: 36519400 DOI: 10.1111/trf.17217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND More granulocyte concentrates (GCs) could be produced for more patients from the same donor if apheresis bags were split and stored for longer periods of time. Hence, we tested the hypothesis that splitting and extension of storage of GCs do not impair granulocyte function or viability. STUDY DESIGN AND METHODS Granulocyte apheresis concentrates were produced using modified fluid gelatin as a separation enhancer, split into two portions, and stored for 24 and 48 h. Granulocyte function, represented by cell migration, reactive oxygen species (ROS) production, and neutrophil extracellular trap formation (NETosis), was measured by live-cell imaging. ROS production, adhesive surface protein expression, and viability were measured by flow cytometry. RESULTS Splitting had no effect on any of the tested parameters. After 24 h of storage, live-cell imaging showed no significant difference in migration, time to maximum ROS production, time to half-maximum NETosis, viability, or CD11b expression, but ROS production induced by phorbol 12-myristate 13-acetate (PMA) decreased from an initial median fluorescence intensity of 1775-590 artificial units. After 48 h, PMA-induced ROS production, viability, and migration declined, as reflected by decreases in median total distance (119 vs. 63.5 μm) and median Euclidean distance (30.75 vs. 14.3 μm). CONCLUSION Splitting GC products has no effect on granulocyte viability or function, but extended storage >24 h does compromise granulocyte function. The findings confirm that GCs should be transfused within 24 h of collection. Longer storage cannot be recommended.
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Affiliation(s)
- Sebastian Koo
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Raubling, Germany.,Department of Anesthesiology, University Hospital Regensburg, Raubling, Germany
| | - Robert Offner
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Raubling, Germany
| | - Sophie-Marie Haile
- Department of Anesthesiology, University Hospital Regensburg, Raubling, Germany
| | - Andreas Brosig
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Raubling, Germany
| | - Viola Hähnel
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Raubling, Germany
| | - Michael Gruber
- Department of Anesthesiology, University Hospital Regensburg, Raubling, Germany
| | - Ralph Burkhardt
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Raubling, Germany
| | - Norbert Ahrens
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University Hospital Regensburg, Raubling, Germany.,Amedes MVZ for Laboratory Diagnostics, University Hospital Regensburg, Raubling, Germany
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5
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Klinkmann G, Doss F, Goudeva L, Doss S, Blasczyk R, Milej M, Koch S, Mitzner S, Altrichter J. Prolonged storage of purified granulocyte concentrates: Introduction of a new purification method. Transfusion 2021; 62:194-204. [PMID: 34783358 DOI: 10.1111/trf.16732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/21/2021] [Accepted: 10/06/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Use of donor granulocyte concentrate (GC) has been limited due to its short storage time of 6-24 h, which is partially due to residual red blood cells (RBCs) and platelets and the resulting lactate production leading to an acidotic milieu. To increase this storage time, we developed a closed system procedure compatible with standard blood bank technologies to remove RBC and platelets and to enrich the GC. METHODS Standard GCs (sGCs) were sedimented, washed twice with 0.9% sodium chloride (NaCl), and resuspended in blood group-identical fresh frozen plasma. The resulting purified GCs (pGCs) were then stored in platelet bags at a cell concentration of about 5 × 107 ± 1.8 × 107 leukocytes/ml without agitation at room temperature for up to 72 h. Cell count and viability, pH, blood gases, phagocytosis, and oxidative burst were monitored daily. RESULTS A significant reduction in RBC (98%) through sedimentation, and platelets (96%) by washing, purified the white blood cell (WBC) population and enriched the granulocytes to 96% of the WBC in the pGC. After 72 h of storage, over 90% of the initial WBC count of pGC remained, was viable (≥97%), and the granulocytes exhibited a high phagocytosis and oxidative burst functionality, comparable to sGC after 24 h. CONCLUSION Purification extends the maximum storage period of GC from 24 to 72 h and may therefore improve the availability of GC and its clinical use.
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Affiliation(s)
- Gerd Klinkmann
- Department of Anaesthesiology and Intensive Care Medicine, University of Rostock, Rostock, Germany
| | | | - Lilia Goudeva
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Sandra Doss
- Artcline GmbH, Rostock, Germany.,Department of Extracorporeal Immunomodulation, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | | | - Stephanie Koch
- Department of Extracorporeal Immunomodulation, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany
| | - Steffen Mitzner
- Artcline GmbH, Rostock, Germany.,Department of Extracorporeal Immunomodulation, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany.,Department of Medicine, Division of Nephrology, Medical Faculty, University of Rostock, Rostock, Germany
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Ma J, Lam IKY, Lau CS, Chan VSF. Elevated Interleukin-18 Receptor Accessory Protein Mediates Enhancement in Reactive Oxygen Species Production in Neutrophils of Systemic Lupus Erythematosus Patients. Cells 2021; 10:cells10050964. [PMID: 33919154 PMCID: PMC8143138 DOI: 10.3390/cells10050964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/19/2022] Open
Abstract
Interleukin-18 receptor accessory protein (IL18RAP) is an indispensable subunit for the IL-18 receptor (IL-18R) complex's ability to mediate high-affinity IL-18 binding and signalling transduction. Interest in IL-18 in systemic lupus erythematosus (SLE) has been mostly focused on its role as a type 1 T helper cell-driving cytokine. The functional significance of IL18RAP in mediating the IL-18-driven response in myeloid cells in SLE remains largely unexplored. This study aimed to investigate the expression and function significance of IL18RAP in neutrophils of SLE patients. By qRT-PCR and Western blot analyses, elevated expressions of IL18RAP mRNA and protein were observed in neutrophils from SLE patients-particularly those with a history of nephritis. IL18RAP expression correlated negatively with complement 3 level and positively with disease activity, with higher expression in patients exhibiting renal and immunological manifestations. The increased IL18RAP expression in SLE neutrophils could be attributed to elevated type I interferon level in sera. Functionally, neutrophils from SLE patients showed higher IL-18-mediated enhancement in reactive oxygen species (ROS) generation, which showed positive correlation with IL18RAP expression and could be neutralized by anti-IL18RAP blocking antibodies. Taken together, our findings suggest that IL-18 could contribute to SLE pathogenesis through mediation of neutrophil dysfunction via the upregulation of IL18RAP expression.
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7
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Sahlin A, Blomgran R, Berlin G. Granulocyte concentrates prepared from residual leukocyte units produced by the Reveos automated blood processing system. Transfus Apher Sci 2019; 59:102682. [PMID: 31812492 DOI: 10.1016/j.transci.2019.102682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Granulocyte concentrates are mainly derived by apheresis technique from donors stimulated with granulocyte colony-stimulating factor and steroids. The automated blood processing system Reveos, which is now increasingly used across the world, separates whole blood into four components, including a residual leukocyte unit containing granulocytes. The aim of this study was to produce an alternative granulocyte concentrate from leukocyte units produced by the Reveos system, and to assess the function of the granulocytes. METHODS The number of granulocytes was measured in residual leukocyte units, derived from whole blood donations, with different volumes ranging from 10 to 40 ml. After deciding the optimal volume of the leukocyte unit (30 ml), ten ABO-matched units were pooled to form a granulocyte concentrate. The function of the granulocytes from residual leukocyte units was assessed by analyzing surface markers, phagocytosis of yeast, and production of reactive oxygen species. RESULTS Residual leukocyte units with a volume of 30 ml contained a median number of 0,7 × 109 granulocytes, and granulocyte concentrates prepared from ten pooled 30 ml-leukocyte units contained a median number of 6,3 × 109 granulocytes. Granulocytes derived from residual leukocyte units displayed surface markers associated with granulocyte function, and capability to phagocytose yeast and produce reactive oxygen species. CONCLUSIONS Granulocyte concentrates prepared from residual leukocyte units contain in vitro functional granulocytes and may be considered as an alternative product in acute situations before regular granulocyte concentrates from stimulated donors are available.
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Affiliation(s)
- Angelica Sahlin
- Department of Clinical Immunology and Transfusion Medicine, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, 581 85 Linköping, Sweden
| | - Robert Blomgran
- Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, 581 85 Linköping, Sweden
| | - Gösta Berlin
- Department of Clinical Immunology and Transfusion Medicine, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, 581 85 Linköping, Sweden.
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8
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West KA, Conry-Cantilena C. Granulocyte transfusions: Current science and perspectives. Semin Hematol 2019; 56:241-247. [DOI: 10.1053/j.seminhematol.2019.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 01/28/2023]
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9
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Mastronardi R, Cleophax S, Begué S, Hurtado-Nedelec M, Gross S, Bocquet T, Djoudi R. [Preparation of pooled granulocytes concentrates from whole blood buffy coats (PGC) as an alternative to apheresis]. Transfus Clin Biol 2019; 26:164-170. [PMID: 31400933 DOI: 10.1016/j.tracli.2019.06.188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The collection of granulocytes by apheresis requires volunteer donor stimulation by corticoids and the use of HES, a compound which is currently challenged by potential safety issues. Preparation of pooled granulocytes concentrates from whole blood buffy coats (PGC) represent an alternative to apheresis with a better benefit/risk for the donors. METHOD Whole blood is collected in a bottom and top blood bag for buffy coat preparation. After centrifugation and separation, buffy coat are obtained. Twenty ABO matched buffy coats are selected for processing into one PGC. Four pools of five buffy coats were made, platelet additive solution is added to each pool, mixed gently and centrifuged. The red cell residue, supernatant and granulocyte rich layer are separated. Two granulocyte rich layers are pooled and added with 70mL of ABO matched plasma from the initial donations (=PGC10). The final PGC (=PGC20) is obtained by pooling two PGC10 into a platelet storage bag. Neutrophil content and in-vitro functionality are assessed at day of preparation (D1) and at expiry hour, 48 hours after collection (D2). RESULTS On N=18, mean: Volume=408±4mL, 2.2*1010±0.24 neutrophils, Hematocrit=18%±3%, 4.7*1011platelets. Viability is well preserved: 95%±6% day of PGC preparation, 85%±7% after 24h of storage (D2). Functionality (ROS production measurement) is well preserved: 1.36±0.25 at D1 and 1.38±0.18 at D2. Expression and modulation of adhesion molecules after stimulation are normal at D1 and slightly decreased at D2 but still normal. CONCLUSIONS PGC20 in vitro characteristics are in conformance with the EDQM guide (V19) and similar to apheresis for granulocytes content and hematocrit. The viability and two mean indicators which explore neutrophil function are well maintained during PGC preparation and after 24 hours of storage.
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Affiliation(s)
- R Mastronardi
- Établissement français du sang- Île-de-France, avenue de l'Île-de-France, 95300 Pontoise, France
| | - S Cleophax
- Établissement français du sang- Île-de-France, avenue de l'Île-de-France, 95300 Pontoise, France
| | - S Begué
- Établissement français du sang, 20, avenue du Stade-de-France, 93218 Saint-Denis, France
| | - M Hurtado-Nedelec
- Inserm U1149, CNRS-ERL8252, hopitaux universitaire Paris Nord Val-de-Seine, 46, rue Henri-Huchard, 75018 Paris, France
| | - S Gross
- Établissement français du sang, 20, avenue du Stade-de-France, 93218 Saint-Denis, France
| | - T Bocquet
- Établissement français du sang- Île-de-France, avenue de l'Île-de-France, 95300 Pontoise, France.
| | - R Djoudi
- Établissement français du sang, 20, avenue du Stade-de-France, 93218 Saint-Denis, France
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10
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Netelenbos T, Massey E, de Wreede LC, Harding K, Hamblin A, Sekhar M, Li A, Ypma PF, Ball L, Zwaginga JJ, Stanworth SJ. The burden of invasive infections in neutropenic patients: incidence, outcomes, and use of granulocyte transfusions. Transfusion 2018; 59:160-168. [PMID: 30383912 PMCID: PMC7379528 DOI: 10.1111/trf.14994] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with prolonged neutropenia caused by chemotherapy or underlying marrow disorders are at risk of invasive bacterial and fungal infections. New treatment options alongside targeted antimicrobial therapy that might improve outcomes include granulocyte transfusions (GTX). To inform the research agenda, a prospective observational cohort study was performed in the Netherlands and United Kingdom. The aim was to describe the incidence, characteristics, and outcomes of patients developing invasive infections and assess patients fulfilling criteria for GTX. STUDY DESIGN AND METHODS All patients receiving myeloablative chemotherapy and anticipated to develop 7 or more days of neutropenia (<0.5 × 109/L) were eligible and followed for the development of invasive infections according to a defined algorithm and mortality up to 100 days. Secondary outcomes were types of infection and eligibility for GTX. RESULTS A total of 471 patients enrolled at six hematology‐oncology departments were followed for 569 neutropenic episodes. Overall, 32.5% of patients developed invasive infections during their first episode. Significant baseline risk factors for developing infections were high comorbidity scores (WHO performance status ≥ 2, hazard ratio [HR], 2.6 [1.7‐3.9]; and hematopoietic cell transplantation‐comorbidity index score ≥ 2 HR 1.3 [0.9‐1.8]). Infections were bacterial (59.4%) and fungal (22.3%). Despite 34 patients (6.3% of all episodes) appearing to meet criteria to receive GTX, only nine patients received granulocytes. The HR for death was 5.8 (2.5‐13.0) for patients with invasive infections. CONCLUSION This study documents that invasive infections are associated with significant mortality. There is a need for new strategies to prevent and treat infections, which may include better understanding of use GTX. See article on page 6–8, in this issue
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Affiliation(s)
- Tanja Netelenbos
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Edwin Massey
- University Hospitals Bristol NHS Foundation Trust and NHS Blood and Transplant Bristol, Bristol, United Kingdom
| | - Liesbeth C de Wreede
- Medical Statistics Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Kay Harding
- University Hospitals Bristol NHS Foundation Trust and NHS Blood and Transplant Bristol, Bristol, United Kingdom
| | - Angela Hamblin
- Oxford University Hospitals NHS Foundation Trust & Oxford BRC Hematology Theme Oxford, Oxford, United Kingdom
| | - Mallika Sekhar
- Department of Hematology, Royal Free Hospital London, London, United Kingdom
| | - Anna Li
- Department of Hematology, Royal Free Hospital London, London, United Kingdom
| | - Paula F Ypma
- Department of Hematology, HAGA Hospital, The Hague, the Netherlands
| | - Lynn Ball
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap Jan Zwaginga
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands.,Center for Clinical Transfusion Research, Sanquin-LUMC, Leiden, the Netherlands
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust & Oxford BRC Hematology Theme Oxford, Oxford, United Kingdom
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11
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Successful Treatment of Invasive Conidiobolus Infection During Therapy for Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2018; 40:e446-e449. [PMID: 28991126 PMCID: PMC5904005 DOI: 10.1097/mph.0000000000000985] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Invasive fungal infections are a serious cause of morbidity and mortality in patients with hematologic malignancies. Conidiobolus species are molds within the order Entomophthorales and may disseminate to become rapidly fatal in immunocompromised individuals. This species of fungal infections are often multidrug resistant (MDR) and present unique therapeutic challenges. Reports of Conidiobolus infections are rare in pediatric oncology. We report the successful treatment of an adolescent male with B-cell lymphoblastic leukemia and MDR invasive sinopulmonary Conidiobolus infection with emphasis on early and aggressive neutrophil support with surgical debridement. The strategies described could be applied to other MDR fungal infections.
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12
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Pagano MB, Morton S, Cohn CS, Gross S, Kutner J, Lewin A, McCullough J, Schweitzer I, Tinmouth AT, West K, Stanworth SJ. An International Registry of Granulocyte Transfusions. Transfus Med Hemother 2018; 45:318-322. [PMID: 30498409 DOI: 10.1159/000492629] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction Granulocyte transfusions are used to either treat or prevent life-threatening infections in neutropenic patients. Current evidence from clinical trials does not support or reject efficacy, nor guide practice. Methods A group of investigators have led the efforts to create an online registry to gather information on granulocyte transfusion practices from as broad a range of international settings. The data forms were adapted from an on-going study in England for electronic data management. Data is collected at the time of the request for granulocytes, weekly, at 28 days, and at 6 months. Information collected includes donor, granulocyte unit, patient and illness characteristics, and outcomes. Results The PROspective GRanulocyte usage and outcomEs Survey (ProGrES) is currently open for data entry. Centres across the UK have collected data on 80 subjects. Five institutions from 4 countries (2 from the US, 1 each from Brazil, and national services in Canada and France) are in the process of joining the study. Other countries have expressed interest. Conclusion It is feasible to develop an international registry of granulocyte transfusions to characterise current practices and describe outcomes. This registry would provide a platform to explore the relationship between intervention and outcomes, and to generate evidence to inform granulocyte transfusion efficacy.
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Affiliation(s)
- Monica B Pagano
- Laboratory Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Suzy Morton
- NHS Blood and Transplant, University Hospitals Birmingham, Birmingham, UK
| | - Claudia S Cohn
- Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Sylvie Gross
- Etablissement Français du Sang, La Plaine-Saint Denis, France
| | - Jose Kutner
- Hemotherapy and Cell Therapy, Hospital Israelita Albert Einstein, Sao Paulo, Bazil
| | - Antoine Lewin
- Medical Affairs and Innovation, Héma-Québec, Montreal, QC, Canada
| | - Jeffrey McCullough
- Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Irwin Schweitzer
- Clinical Epidemiology Program Center for Transfusion Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alan T Tinmouth
- Departments of Medicine and Laboratory Medicine and Pathology, Ottawa Hospital Center for Transfusion Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kamille West
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Simon J Stanworth
- NHS Blood & Transplant/Oxford University Hospitals NHS Foundation Trust, and University of Oxford; Oxford, UK
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Busca A, Cesaro S, Teofili L, Delia M, Cattaneo C, Criscuolo M, Marchesi F, Fracchiolla NS, Valentini CG, Farina F, Di Blasi R, Prezioso L, Spolzino A, Candoni A, del Principe MI, Verga L, Nosari A, Aversa F, Pagano L. SEIFEM 2017: from real life to an agreement on the use of granulocyte transfusions and colony-stimulating factors for prophylaxis and treatment of infectious complications in patients with hematologic malignant disorders. Expert Rev Hematol 2018; 11:155-168. [DOI: 10.1080/17474086.2018.1420472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Alessandro Busca
- SSD Trapianto Cellule Staminali, A.O.U. Citta’ della Salute, Torino, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - Luciana Teofili
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Delia
- Dipartimento dell’Emergenza e dei Trapianti Di Organo, U.O Ematologia con Trapianto - Azienda Ospedaliero-Universitaria - Policlinico di Bari, Italy
| | | | - Marianna Criscuolo
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit Regina Elena National Cancer Institute, Rome, Italy
| | | | - Caterina Giovanna Valentini
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Farina
- Unità di ematologia e trapianti di midollo osseo, IRCCS San Raffaele, Milano, Italy
| | - Roberta Di Blasi
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Anna Candoni
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata di Udine, Italy
| | | | - Luisa Verga
- Ematologia adulti e CTA ASST Monza, Universita’ Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | - Annamaria Nosari
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Milano.Italy
| | | | - Livio Pagano
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
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14
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Granulocyte Transfusions: A Critical Reappraisal. Biol Blood Marrow Transplant 2017; 23:2034-2041. [DOI: 10.1016/j.bbmt.2017.07.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 07/31/2017] [Indexed: 11/23/2022]
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15
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Granulocyte transfusions: A concise review for practitioners. Cytotherapy 2017; 19:1256-1269. [PMID: 28916227 DOI: 10.1016/j.jcyt.2017.08.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/09/2017] [Accepted: 08/15/2017] [Indexed: 01/05/2023]
Abstract
Granulocyte transfusions (GTXs) have been used to treat and prevent infections in neutropenic patients for more than 40 years, despite persistent controversy regarding their efficacy. This narrative review attempts to complement recent systematic reviews by the Cochrane Collaboration and provide both historical context and critical assessment of the most significant clinical studies published over the years. The data suggest that properly collected and promptly infused granulocytes are active against infections, both bacterial and fungal. The most important question that remains unanswered is in which patients the administration of granulocytes will be beneficial. The preponderance of evidence suggests that granulocyte transfusions may be efficacious in few select cases as a temporizing measure to control an infection that is expected (or proven) to be refractory to optimal antimicrobial treatment, and that could otherwise be controlled by marrow recovery, which is expected to happen. In this regard, they are best considered a "bridge" that grants enough time for the recipient to develop their own response to the infection. The challenges to use GTXs successfully are both clinical, in terms of timely identifying the patients who may benefit, and logistical, in terms of optimal selection of donors and collection technique.
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16
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Morton S, Mijovic A, Marks DI, Griffin J, Massey E, Bhatnagar N, Stanworth SJ. Use of granulocyte transfusions among haematology units in England and North Wales. Transfus Med 2017; 28:243-248. [DOI: 10.1111/tme.12452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- S. Morton
- Medical Department; NHS Blood and Transplant; Birmingham UK
| | - A. Mijovic
- Department of Haematology; Kings College Hospital; London UK
| | - D. I. Marks
- Clinical Haematology; University Hospitals Bristol; Bristol UK
| | - J. Griffin
- Clinical Haematology; University Hospitals Bristol; Bristol UK
| | - E. Massey
- Medical Department, NHS Blood and Transplant; Bristol
| | - N. Bhatnagar
- Paediatric Oncology and Haematology; Oxford University Hospitals; Oxford UK
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17
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West KA, Gea-Banacloche J, Stroncek D, Kadri SS. Granulocyte transfusions in the management of invasive fungal infections. Br J Haematol 2017; 177:357-374. [PMID: 28295178 DOI: 10.1111/bjh.14597] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/14/2016] [Indexed: 01/01/2023]
Abstract
Granulocyte transfusions have a long history of being used in patients with neutropenia or neutrophil dysfunction to prevent and treat invasive fungal infections. However, there are limited and conflicting data concerning its clinical effectiveness, considerable variations in current granulocyte transfusion practices, and uncertainties about its benefit as an adjunct to modern antifungal therapy. In this review, we provide an overview on granulocyte transfusions and summarize the evidence on their role in the prevention and treatment of invasive fungal infections.
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Affiliation(s)
- Kamille A West
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Juan Gea-Banacloche
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, MD, USA
| | - David Stroncek
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
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18
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van de Geer A, Gazendam RP, Tool ATJ, van Hamme JL, de Korte D, van den Berg TK, Zeerleder SS, Kuijpers TW. Characterization of buffy coat-derived granulocytes for clinical use: a comparison with granulocyte colony-stimulating factor/dexamethasone-pretreated donor-derived products. Vox Sang 2017; 112:173-182. [PMID: 28120426 DOI: 10.1111/vox.12481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 10/10/2016] [Accepted: 10/17/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Buffy coat-derived granulocytes have been described as an alternative to the apheresis product from donors pretreated with dexamethasone and granulocyte colony-stimulating factor (G-CSF). The latter is - dependent on the local and national settings - obtained following a demanding and time-consuming procedure, which is undesirable in critically ill septic patients. In contrast, buffy coat-derived products have a large volume and are often heavily contaminated with red cells and platelets. We developed a new pooled buffy coat-derived product with high purity and small volume, and performed a comprehensive functional characterization of these granulocytes. MATERIALS AND METHODS We pooled ten buffy coats following the production of platelet concentrates. Saline 0·9% was added to decrease the viscosity and the product was split into plasma, red cells and a 'super' buffy coat. Functional data of the granulocytes were compared to those obtained with granulocytes from healthy controls and G-CSF/dexamethasone-pretreated donors. RESULTS Buffy coat-derived granulocytes showed adhesion, chemotaxis, reactive oxygen species production, degranulation, NETosis and in vitro killing of Staphylococcus aureus, Escherichia coli and Aspergillus species comparable to control and G-CSF/dexamethasone-derived granulocytes. Candida killing was superior compared to G-CSF/dexamethasone-derived granulocytes. Immunophenotyping was normal; especially no signs of activation in the buffy coat-derived granulocytes were seen. Viability was reduced. Buffy coats are readily available in the regular blood production process and would take away the concerns around the apheresis product. CONCLUSION The product described appears a promising alternative for transfusion purposes.
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Affiliation(s)
- A van de Geer
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - R P Gazendam
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - A T J Tool
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - J L van Hamme
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - D de Korte
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, The Netherlands
| | - T K van den Berg
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - S S Zeerleder
- Department of Immunopathology, Sanquin Research, Amsterdam, The Netherlands.,Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - T W Kuijpers
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Department of Pediatric Hematology, Immunology & Infectious disease, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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19
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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20
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Granulocyte transfusions in critically ill children with prolonged neutropenia: side effects and survival rates from a single-center analysis. Eur J Pediatr 2016; 175:1361-9. [PMID: 27631588 DOI: 10.1007/s00431-016-2774-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/21/2016] [Accepted: 08/30/2016] [Indexed: 12/22/2022]
Abstract
UNLABELLED Granulocyte transfusions for neutropenic patients have been used for over 40 years, although effectiveness, indications, and both patient and donor safety remain debated. This single-center study assessed the side effects, clinical course, and survival of granulocyte transfusions in critically ill pediatric patients, with underlying hemato-oncological disorders, prolonged neutropenia, and proven or suspected severe infection. Donor-specific side effects and influence of donor-specific characteristics on patient outcome were also investigated. A median of 4.02 × 10(10) cells was collected from 39 healthy donors for 118 granulocyte concentrates. Donors reported no significant side effects. Complications for patients were frequent but mostly minor and included vomiting, hypotension, and dyspnea. In one episode of life-threatening dyspnea, association with the granulocyte transfusion could not be ruled out. Overall survival on day 100 was 61.9 %. Patients received a median of 0.13 × 10(10) cells per kg body weight. Doses above this median were associated with a significantly better survival. Lower patient weight and age-/sex-adjusted weight were also associated with better survival. CONCLUSION Granulocyte mobilization and collection is a safe practice. Transfusions are well tolerated in critically ill patients. Patient weight and transfused cells per kg bodyweight are major determinants of survival in pediatric patients. WHAT IS KNOWN • Granulocyte transfusions for neutropenic patients have been used for over 40 years • The effectiveness of the technique remains controversial • Patient and donor safety remain debated • New mobilization protocols generate higher yields of granulocytes What is new: • Granulocyte collection can safely be performed • Granulocytes can safely be administered to patients • Lower patient weight and age-/sex-adjusted weight are associated with better survival rates • Patients receiving above 0.13 × 10 (10) cells per kg body weight had an excellent outcome • Further standardized, prospective studies are warranted.
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21
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Taha M, Kalab M, Yi QL, Maurer E, Jenkins C, Schubert P, Ramirez-Arcos S. Bacterial survival and distribution during buffy coat platelet production. Vox Sang 2016; 111:333-340. [PMID: 27432557 DOI: 10.1111/vox.12427] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/09/2016] [Accepted: 06/03/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES At Canadian Blood Services, buffy coat (BC) platelet concentrates (BC-PCs) show a generally lower bacterial contamination rate than apheresis PCs. This study investigated whether the PC production method contributes to this observation. MATERIALS AND METHODS Whole blood (WB) inoculated with eight bacterial strains was processed using the BC method. Bacteria were enumerated throughout BC-PC production and subsequent PC storage. Endotoxin production and bacterial adhesion to PC bags were evaluated during PC storage. PC quality was monitored by CD62P expression (flow cytometry) and changes in dynamic light scattering (ThromboLUX® ). RESULTS During overnight WB hold, Staphylococcus epidermidis titres remained unchanged, commercial Escherichia coli and Klebsiella pneumoniae were eliminated and the remaining organisms proliferated to high concentrations. Through BC-PC production, bacteria segregated preferentially towards the cellular fractions compared to plasma (P < 0·05). During PC storage, most bacteria adhered to the PC bags and Gram negatives produced clinically significant endotoxin levels. Changes in CD62P expression or ThromboLUX scoring did not consistently reflect bacterial contamination in BC-PCs. CONCLUSION WB hold during BC-PC production does not have a broad-spectrum bactericidal effect, and therefore, other factors contribute to low rates of contamination in BC-PCs.
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Affiliation(s)
- M Taha
- Canadian Blood Services, Ottawa, ON, Canada
| | - M Kalab
- Agriculture and Agri-Food Canada, Ottawa, ON, Canada
| | - Q-L Yi
- Canadian Blood Services, Ottawa, ON, Canada
| | - E Maurer
- LightIntegra, Vancouver, BC, Canada
| | - C Jenkins
- Canadian Blood Services, Ottawa, ON, Canada
| | - P Schubert
- Canadian Blood Services, Ottawa, ON, Canada
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22
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Estcourt LJ, Stanworth SJ, Hopewell S, Doree C, Trivella M, Massey E. Granulocyte transfusions for treating infections in people with neutropenia or neutrophil dysfunction. Cochrane Database Syst Rev 2016; 4:CD005339. [PMID: 27128488 PMCID: PMC4930145 DOI: 10.1002/14651858.cd005339.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Despite modern antimicrobials and supportive therapy bacterial and fungal infections are still major complications in people with prolonged disease-related or treatment-related neutropenia. Transfusions of granulocytes have a long history of usage in clinical practice to support and treat severe infection in high-risk groups of patients with neutropenia or neutrophil dysfunction. However, there is considerable current variability in therapeutic granulocyte transfusion practice, and uncertainty about the beneficial effect of transfusions given as an adjunct to antibiotics on mortality. This is an update of a Cochrane review first published in 2005. OBJECTIVES To determine the effectiveness and safety of granulocyte transfusions compared to no granulocyte transfusions as adjuncts to antimicrobials for treating infections in people with neutropenia or disorders of neutrophil function aimed at reducing mortality and other adverse outcomes related to infection. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 2). MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1980) and ongoing trial databases to 11 February 2016. SELECTION CRITERIA RCTs comparing people with neutropenia or disorders of neutrophil dysfunction receiving granulocyte transfusions to treat infection with a control group receiving no granulocyte transfusions. Neonates are the subject of another Cochrane review and were excluded from this review. There was no restriction by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by the Cochrane Collaboration. MAIN RESULTS We identified 10 trials that met the inclusion criteria with a total of 587 participants. We also identified another ongoing trial. These trials were conducted between 1975 and 2015. None of the studies included people with neutrophil dysfunction. The studies differed in the type of infections they included. Six studies included both children and adults, however data were not reported separately for children and adults. The two newest studies gave granulocyte colony stimulating factor (G-CSF) to donors; both were stopped early due to lack of recruitment. Three studies re-randomised participants and therefore quantitative analysis was unable to be performed.Overall the quality of the evidence was very low to low across different outcomes according to GRADE methodology. This was due to many of the studies being at high risk of bias, and many of the outcomes being imprecise.There may be no difference in all-cause mortality over 30 days between participants receiving therapeutic granulocyte transfusions and those that did not (six studies; 321 participants; RR 0.75, 95% CI 0.54 to 1.04; very low-quality evidence). There were no differences between the granulocyte dose subgroups (< 1 x 10(10) per day versus ≥ 1 x 10(10) per day) (test for subgroup differences P = 0.39). There was a difference in all-cause mortality between the studies based on the age of the study (published before 2000 versus published 2000 or later) (test for subgroup differences P = 0.03). There was no difference in all-cause mortality between participants receiving granulocyte transfusions and those that did not in the newest study (one study; 111 participants; RR 1.10, 95% CI 0.70 to 1.73, low-quality evidence). There may be a reduction in all-cause mortality in participants receiving granulocyte transfusions compared to those that did not in studies published before the year 2000 (five studies; 210 participants; RR 0.53, 95% CI 0.33 to 0.85; low-quality evidence).There may be no difference in clinical reversal of concurrent infection between participants receiving therapeutic granulocyte transfusions and those that did not (five studies; 286 participants; RR 0.98, 95% CI 0.81 to 1.19; low-quality evidence).There is insufficient evidence to determine whether there is a difference in pulmonary serious adverse events (1 study; 24 participants; RR 0.85, 95% CI 0.38 to 1.88; very low-quality evidence).None of the studies reported number of days on therapeutic antibiotics, number of adverse events requiring discontinuation of treatment, or quality of life.Six studies reported their funding sources and all were funded by governments or charities. AUTHORS' CONCLUSIONS In people who are neutropenic due to myelosuppressive chemotherapy or a haematopoietic stem cell transplant, there is insufficient evidence to determine whether granulocyte transfusions affect all-cause mortality. To be able to detect a decrease in all-cause mortality from 35% to 30% would require a study containing at least 2748 participants (80% power, 5% significance). There is low-grade evidence that therapeutic granulocyte transfusions may not increase the number of participants with clinical resolution of an infection.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Edwin Massey
- NHS Blood and TransplantNorth Bristol ParkNorthway, FiltonBristolUKBS34 7QH
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23
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Estcourt LJ, Stanworth SJ, Doree C, Blanco P, Hopewell S, Trivella M, Massey E. Granulocyte transfusions for preventing infections in people with neutropenia or neutrophil dysfunction. Cochrane Database Syst Rev 2015; 2015:CD005341. [PMID: 26118415 PMCID: PMC4538863 DOI: 10.1002/14651858.cd005341.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite modern antimicrobials and supportive therapy, bacterial and fungal infections are still major complications in people with prolonged disease-related or therapy-related neutropenia. Since the late 1990s there has been increasing demand for donated granulocyte transfusions to treat or prevent severe infections in people who lack their own functional granulocytes. This is an update of a Cochrane review first published in 2009. OBJECTIVES To determine the effectiveness and safety of prophylactic granulocyte transfusions compared with a control population not receiving this intervention for preventing all-cause mortality, mortality due to infection, and evidence of infection due to infection or due to any other cause in people with neutropenia or disorders of neutrophil function. SEARCH METHODS We searched for randomised controlled trials (RCTs) and quasi-RCTs in the Cochrane Central Register of Controlled Trials (Cochrane Library 2015, Issue 3), MEDLINE (from 1946), EMBASE (from 1974), CINAHL (from 1937), theTransfusion Evidence Library (from 1980) and ongoing trial databases to April 20 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing people receiving granulocyte transfusions to prevent the development of infection with a control group receiving no granulocyte transfusions. Neonates are the subject of another Cochrane review and were excluded from this review. There was no restriction by outcomes examined, but this review focuses on mortality, mortality due to infection and adverse events. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Twelve trials met the inclusion criteria. One trial is still ongoing, leaving a total of 11 trials eligible involving 653 participants. These trials were conducted between 1978 and 2006 and enrolled participants from fairly comparable patient populations. None of the studies included people with neutrophil dysfunction. Ten studies included only adults, and two studies included children and adults. Ten of these studies contained separate data for each arm and were able to be critically appraised. One study re-randomised people and therefore quantitative analysis was unable to be performed.Overall, the quality of the evidence was very low to low across different outcomes according to GRADE methodology. This was due to many of the studies being at high risk of bias, and many of the outcome estimates being imprecise.All-cause mortality was reported for nine studies (609 participants). There was no difference in all-cause mortality over 30 days between people receiving prophylactic granulocyte transfusions and those that did not (seven studies; 437 participants; RR 0.92, 95% CI 0.63 to 1.36, very low-quality evidence).Mortality due to infection was reported for seven studies (398 participants). There was no difference in mortality due to infection over 30 days between people receiving prophylactic granulocyte transfusions and those that did not (six studies; 286 participants; RR 0.69, 95% CI 0.33 to 1.44, very low-quality evidence).The number of people with localised or systemic bacterial or fungal infections was reported for nine studies (609 participants). There were differences between the granulocyte dose subgroups (test for subgroup differences P = 0.01). There was no difference in the number of people with infections over 30 days between people receiving prophylactic granulocyte transfusions and those that did not in the low-dose granulocyte group (< 1.0 x 10(10) granulocytes per day) (four studies, 204 participants; RR 0.84, 95% CI 0.58 to 1.20; very low-quality evidence). There was a decreased number of people with infections over 30 days in the people receiving prophylactic granulocyte transfusions in the intermediate-dose granulocyte group (1.0 x 10(10) to 4.0 x 10(10) granulocytes per day) (4 studies; 293 participants; RR 0.40, 95% CI 0.26 to 0.63, low-quality evidence).There was a decreased number of participants with bacteraemia and fungaemia in the participants receiving prophylactic granulocyte transfusions (nine studies; 609 participants; RR 0.45, 95% CI 0.30 to 0.65, low-quality evidence).There was no difference in the number of participants with localised bacterial or fungal infection in the participants receiving prophylactic granulocyte transfusions (six studies; 296 participants; RR 0.75, 95% CI 0.50 to 1.14; very low-quality evidence).Serious adverse events were only reported for participants receiving granulocyte transfusions and donors of granulocyte transfusions. AUTHORS' CONCLUSIONS In people who are neutropenic due to myelosuppressive chemotherapy or a haematopoietic stem cell transplant, there is low-grade evidence that prophylactic granulocyte transfusions decrease the risk of bacteraemia or fungaemia. There is low-grade evidence that the effect of prophylactic granulocyte transfusions may be dose-dependent, a dose of at least 10 x 10(10) per day being more effective at decreasing the risk of infection. There is insufficient evidence to determine any difference in mortality rates due to infection, all-cause mortality, or serious adverse events.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Patricia Blanco
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Edwin Massey
- NHS Blood and TransplantNorth Bristol ParkNorthway, FiltonBristolUKBS34 7QH
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Abstract
Bacterial and fungal infections continue to be a major cause of morbidity and mortality in severely neutropenic patients undergoing aggressive chemotherapy regimens or hematopoietic stem cell transplantation. Traditional granulocyte transfusion therapy, a logical approach in treating these infections, has been available for many years, and several controlled studies have shown this therapy to be useful. However, granulocyte transfusion therapy fell out of favor because the results were not clinically impressive, and adverse results were reported. These disappointing results were felt to be, in part, because of the low doses of granulocytes provided. More recent studies have attempted to increase the numbers of transfused cells by stimulating normal granulocyte donors with G-CSF (+/-corticosteroids). With these techniques, the number of granulocytes transfused can be increased 3-4 fold. The cells have been shown to circulate in recipients, and daily transfusions are capable of maintaining normal or near-normal blood neutrophil counts in previously severely neutropenic patients. The cells appear to function normally by a variety of in vitro and in vivo tests. Clinical benefit, as defined by survival or clearance of infection, has not been definitively determined. Results of an ongoing randomized controlled clinical trial should be available in the near future.
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Affiliation(s)
- Anthony A. Marfin
- Puget Sound Blood Center, Seattle, WA, USA
- Current Address: HIV Prevention Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Thomas H. Price
- Puget Sound Blood Center, Seattle, WA, USA
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
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25
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Massey E, Harding K, Kahan BC, Llewelyn C, Wynn R, Moppett J, Robinson SP, Green A, Lucas G, Sadani D, Liakopoulou E, Bolton-Maggs P, Marks DI, Stanworth S. The granulocytes in neutropenia 1 (GIN 1) study: a safety study of granulocytes collected from whole blood and stored in additive solution and plasma. Transfus Med 2012; 22:277-84. [PMID: 22591484 DOI: 10.1111/j.1365-3148.2012.01152.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/AIM To evaluate the safety of transfusing pooled, whole blood-derived granulocytes in additive solution and plasma (GASP) in 30 recipients. BACKGROUND Demand for granulocytes in England has increased five-fold. With the advantages of reduced red cell, plasma and overall volume, GASP maintains function in vitro. METHODS AND MATERIALS Observations were recorded prior to and post transfusion. Increments were recorded at 1 h and the following morning. Leucocyte antibody screening was undertaken prior to and at 1-6 months following transfusion. RESULTS Thirty patients aged between 8 months and 68 years received 221 GASP in 148 transfusion episodes. GASP contained an average of 1.0 × 10(10) granulocytes in 207 mL. Adults usually received two packs and children 10-20 mL kg(-1). Children and adults received a median [interquartile range (IQR)] dose of 12.5 (9.1-25.3) and 19.7 (12.0-25.8) × 10(9) granulocytes per transfusion, respectively. There was one episode of transfusion-associated circulatory overload (TACO) in a patient with chronic cardiac failure following 600 mL of unpooled granulocytes, other fluids and one GASP. New leucocyte alloimmunisation occurred in 3/30 recipients 10%. No other significant reactions were reported. Median peripheral blood neutrophil increments at 1 h post transfusion were 0.06 (IQR, 0.01-0.17) in children and (0.03) (IQR, 0-0.16) in adults. CONCLUSION GASP has a similar safety profile to other sources of granulocytes for patients with refractory infection or in need of secondary prophylactic transfusion. Further studies are required to clarify the role of GASP in the treatment of neutropenic patients.
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Affiliation(s)
- Edwin Massey
- NHS Blood and Transplant, North Bristol Park, Northway Filton, Bristol BS34 7QH, UK.
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Akaihata M, Kikuta A, Mochizuki K, Nemoto K, Ito M, Sano H, Kobayashi S, Ohto H, Hosoya M. Maintenance of surface antigens and the absence of an apoptotic marker are observed during storage of granulocyte concentrates collected by bag separation method. Transfus Apher Sci 2012; 47:43-7. [PMID: 22480955 DOI: 10.1016/j.transci.2012.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/12/2012] [Accepted: 03/12/2012] [Indexed: 11/30/2022]
Abstract
Granulocytes were collected by the bag separation method and stored in whole blood for up to 72h. We evaluated the expressions of various surface antigens: CD62L, CD11b, CD18, CD64, CD16b, and CD95. Apoptosis was assessed both by flow cytometry and by light microscopy. Expression levels of all the surface antigens were shown to be maintained during storage for up to 72h. Approximately 80% of granulocytes were annexin V negative until 72h after collection. The storage of granulocyte concentrates collected by the bag separation method may maintain granulocyte surface antigens and lack an apoptotic marker.
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Affiliation(s)
- M Akaihata
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan.
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28
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Adisa O, Hendrickson JE, Hopkins CK, Katzenstein HM, Josephson CD. Polycythemia in an infant secondary to granulocyte transfusions. Pediatr Blood Cancer 2011; 57:1236-8. [PMID: 21370438 PMCID: PMC3568762 DOI: 10.1002/pbc.23080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 01/20/2011] [Indexed: 11/07/2022]
Abstract
Granulocyte transfusions may be useful for neutropenic pediatric patients with refractory bacterial or fungal infections. Many potential adverse sequelae associated with granulocyte transfusions are well recognized, including febrile reactions, fluid overload, alloimmunization, and lung injury. Other potential adverse sequelae, however, are less well known. This case report describes an infant with familial hemophagocytic lymphohistiocytosis who developed polycythemia (hemoglobin 10-17.6 g/dl) following four daily transfusions of 20 ml/kg of apheresis collected, steroid stimulated donor granulocytes. Expanded knowledge of potential risks of transfused granulocytes will allow for rapid recognition of transfusion-related complications, should they occur.
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Affiliation(s)
- Olufolake Adisa
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, GA
| | - Jeanne E. Hendrickson
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, GA
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Howard M. Katzenstein
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, GA
| | - Cassandra D. Josephson
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, GA
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
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Massey E, Paulus U, Doree C, Stanworth S. Granulocyte transfusions for preventing infections in patients with neutropenia or neutrophil dysfunction. Cochrane Database Syst Rev 2009:CD005341. [PMID: 19160254 DOI: 10.1002/14651858.cd005341.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Since the late 1990s there has been increasing demand for donated granulocyte transfusions to treat or prevent severe infections in patients who lack their own functional granulocytes. Other than in neonates, no systematic reviews have been performed for over 10 years relating to the efficacy of prophylactic granulocyte transfusions. OBJECTIVES To determine the effectiveness and safety of granulocyte transfusions compared with a control population not receiving this intervention for preventing mortality due to infection or due to any other cause in patients with neutropenia or disorders of neutrophil function. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008, MEDLINE, EMBASE and other specialised databases up to October 2008. We also searched reference lists of articles and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing patients receiving granulocyte transfusions to prevent the development of infection with a control group receiving no granulocyte transfusions. Neonates have been the subject of a recent review and were excluded. There was no restriction by outcomes examined, but this review focuses on mortality, mortality due to infection and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently assessed potentially relevant studies for inclusion. Data were extracted by two review authors and the methodological quality was examined. Data were analysed using random and fixed effects models. MAIN RESULTS Ten trials met the inclusion criteria. Allocation in all trials was random, with the control arm receiving no prophylactic therapy, except one trial in which the control group received specific prophylactic antibiotics. One study reported biological randomisation based upon the availability of suitably matched, related donors rather than strict randomisation. All trials were conducted over twenty years ago with one exception, a study from 2006 in which donors were pre-medicated with granulocyte colony stimulating factor (G-CSF) resulting in significantly higher mean doses of granulocytes collected for transfusion. Different policies otherwise applied for the schedule for transfusion, method of granulocyte procurement and criteria for defining infection. Combining the results showed a relative risk (RR) for mortality of 0.94 (95% confidence intervals (CI) 0.71 to 1.25). Exclusion of the two trials which reported transfusion of an average number of granulocytes below 1 x 10(10) indicated a summary RR for mortality and mortality due to infection of 0.89 (CI 0.64 to 1.24) and 0.36 (0.14 to 0.96) respectively. IMPLICATIONS FOR CLINICAL PRACTICE The controlled trials that have been identified raise the possibility that prophylactic granulocyte transfusions at a dose of at least 1 x 10(10) may reduce the risk of mortality from infection. Overall mortality was not affected. However, the majority of studies were performed decades ago, and standards of supportive care have advanced considerably. These earlier trials were also based on transfusing lower yields of collected granulocytes than currently recommended. It is difficult to recommend prophylactic granulocyte transfusions outside the setting of ongoing controlled trials, given the resource and cost implications. IMPLICATIONS FOR RESEARCH Larger trials are needed to establish the validity of the potential benefits raised by this review, in view of the methodological limitations, the small sample sizes and the heterogeneous definitions of infection that were encountered in the included studies.
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Affiliation(s)
- Edwin Massey
- NHS Blood and Transplant , North Bristol Park, Northway, Filton, Bristol, UK, BS34 7QH.
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:684-93. [DOI: 10.1097/aco.0b013e328312c01b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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